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Background: Specific guidelines to manage caesarean delivery anaesthesia are lacking. A European multicentre study, ACCESS investigates caesarean delivery anaesthesia management in European centres. In order to identify ACCESS participating centres, a registration survey was created., Objective: The aim of the current report is to describe the characteristics of ACCESS study participating centres, the rationale for the ACCESS study and the study methodology., Design and Setting: The ACCESS study is a European multicentre cross-sectional study to describe anaesthesia management for caesarean delivery (CD) using a snapshot (2-week) design. The ACCESS registration survey gathered: contact details for National Coordinators (NC); Lead Investigators (LI) per centre; centre annual CD volume; expected no. of CD during 2-week snapshot window; centre practice information; data collection language. The ACCESS registration survey was launched July 2022 (Google Forms, Google Inc., Mountain View, CA, USA) and distributed through personal connections, national and international societies, social media networks, during Euroanaesthesia 2023, through the European Society of Anaesthesiology and Intensive Care newsletter., Results: The ACCESS registration survey identified Lead Investigators for 418 centres, in 32 countries, representing an anticipated number of 15,073 CD cases over the planned 12-month study period. A median (range) of 20 (2 to 400) CD cases are anticipated per centre during the 2-week snapshot window. Most 366/418 (87.6%) centres are small, ≤2000 annual CD cases, 42 are medium 2000-5000 cases and 10 are large, ≥5000 annual CD cases. Registered centres reported in 134 (32.0%) centres that anaesthesia for caesarean delivery is performed mostly by a specialist obstetric anaesthesiologist., Conclusion: The ACCESS registration survey revealed variability in volume and CD practice as well as training-levels and staffing among European countries. The ACCESS study (https://www.access-study.org/) aims to generate practice data to guide CD anaesthetic management strategies., (© 2024 The Authors. Acta Anaesthesiologica Scandinavica published by John Wiley & Sons Ltd on behalf of Acta Anaesthesiologica Scandinavica Foundation.)

Background: Pregnant women with Marfan syndrome (MS) have a high risk of aortic dissection around delivery and their optimal management requires a multi-disciplinary approach, including proper cardio-obstetric care and adequate pain management during labor, which may be difficult due to the high prevalence of dural ectasia (DE) in these patients., Objectives: To evaluate the multidisciplinary management of MS patients during labor., Methods: Nineteen pregnant women (31 pregnancies) with MS were followed by a multi-disciplinary team (cardiologist, obstetrician, anesthesiologist) prior to delivery., Results: Two patients had kyphoscoliosis; none had previous spine surgery nor complaints compatible with DE. In eight pregnancies (7 patients), aortic root diameter (ARd) before pregnancy was 40 to 46 mm. In this high-risk group, one patient underwent elective termination, two underwent an urgent cesarean section (CS) under general anesthesia, and five had elective CS; two under general anesthesia (GA), and three under spinal anesthesia. In 23 pregnancies (12 patients), ARd was < 40 mm. In this non-high-risk group three pregnancies (1 patient) were electively terminated. Of the remaining 20 deliveries (11 patients), 14 were vaginal deliveries, 9 with epidural analgesia and 5 without. Six patients had a CS; four under GA and two2 under spinal anesthesia. There were no epidural placement failures and no failed responses. There were 2 cases of aortic dissection, unrelated to the anesthetic management., Conclusions: The optimal anesthetic strategy during labor in MS patients should be decided by a multi-disciplinary team. Anesthetic complications due to DE were not encountered during neuraxial block.

General anaesthesia for obstetric surgery has distinct characteristics that may contribute towards a higher risk of accidental awareness during general anaesthesia. The primary aim of this study was to investigate the incidence, experience and psychological implications of unintended conscious awareness during general anaesthesia in obstetric patients. From May 2017 to August 2018, 3115 consenting patients receiving general anaesthesia for obstetric surgery in 72 hospitals in England were recruited to the study. Patients received three repetitions of standardised questioning over 30 days, with responses indicating memories during general anaesthesia that were verified using interviews and record interrogation. A total of 12 patients had certain/probable or possible awareness, an incidence of 1 in 256 (95%CI 149-500) for all obstetric surgery. The incidence was 1 in 212 (95%CI 122-417) for caesarean section surgery. Distressing experiences were reported by seven (58.3%) patients, paralysis by five (41.7%) and paralysis with pain by two (16.7%). Accidental awareness occurred during induction and emergence in nine (75%) of the patients who reported awareness. Factors associated with accidental awareness during general anaesthesia were: high BMI (25-30 kg.m -2 ); low BMI (<18.5 kg.m -2 ); out-of-hours surgery; and use of ketamine or thiopental for induction. Standardised psychological impact scores at 30 days were significantly higher in awareness patients (median (IQR [range]) 15 (2.7-52.0 [2-56]) than in patients without awareness 3 (1-9 [0-64]), p = 0.010. Four patients had a provisional diagnosis of post-traumatic stress disorder. We conclude that direct postoperative questioning reveals high rates of accidental awareness during general anaesthesia for obstetric surgery, which has implications for anaesthetic practice, consent and follow-up., (© 2021 Association of Anaesthetists.)

At the onset of the global pandemic of COVID-19 (SARS-CoV-2), guidelines recommended using regional anaesthesia for caesarean section in preference to general anaesthesia. National figures from the UK suggest that 8.75% of over 170,000 caesarean sections are performed under general anaesthetic. We explored whether general anaesthesia rates for caesarean section changed during the peak of the pandemic across six maternity units in the north-west of England. We analysed anaesthetic information for 2480 caesarean sections across six maternity units from 1 April to 1 July 2020 (during the pandemic) and compared this information with data from 2555 caesarean sections performed at the same hospitals over a similar period in 2019. Primary outcome was change in general anaesthesia rate for caesarean section. Secondary outcomes included overall caesarean section rates, obstetric indications for caesarean section and regional to general anaesthesia conversion rates. A significant reduction (7.7 to 3.7%, p < 0.0001) in general anaesthetic rates, risk ratio (95%CI) 0.50 (0.39-0.93), was noted across hospitals during the pandemic. Regional to general anaesthesia conversion rates reduced (1.7 to 0.8%, p = 0.012), risk ratio (95%CI) 0.50 (0.29-0.86). Obstetric indications for caesarean sections did not change (p = 0.17) while the overall caesarean section rate increased (28.3 to 29.7%), risk ratio (95%CI) 1.02 (1.00-1.04), p = 0.052. Our analysis shows that general anaesthesia rates for caesarean section declined during the peak of the pandemic. Anaesthetic decision-making, recommendations from anaesthetic guidelines and presence of an on-site anaesthetic consultant in the delivery suite seem to be the key factors that influenced this decline., (© 2020 Association of Anaesthetists.)

Objective: Although a recurrent question in clinical practice, the management of Chiari malformation type I (CMI) and/or syringomyelia during pregnancy and delivery is still debated. The aim of this study was to investigate the modalities of delivery and anesthesia in women presenting with CMI and/or syringomyelia at a national reference center, and to question their potential role in the natural history of these conditions., Study Design: We conducted a retrospective cohort study using a standardized questionnaire, a customized clinical severity score and data from medical records., Results: 83 patients were included in the final analysis: 32 had CMI without syringomyelia, 27 had CMI with syringomyelia and 24 had non-foraminal syringomyelia. Most patients (55/83) were not diagnosed at the time of their pregnancy, 12 had surgery before being pregnant and 16 were diagnosed but not operated. Most women underwent vaginal delivery (62 %) and neuraxial (i.e. epidural or spinal) anesthesia (69 %). However, the proportion of cesarean procedures increased to 53.6 % and even 83.3 % when considering only patients already diagnosed or operated on, respectively. Nonetheless, neither vaginal compared to cesarean delivery (change in clinically severity score: -1.5 ± 0.4 versus -0.9 ± 0.4, p = 0.4) nor neuraxial compared to general anesthesia (-1.2 ± 0.3 versus -1.5 ± 0.6, p = 0.7) were associated with increased clinical deterioration., Conclusion: Although individual evaluation is mandatory, this study supports that neither delivery nor anesthesia modalities affect the natural history for the vast majority of patients with CMI and/or syringomyelia., Competing Interests: Declaration of Competing Interest The authors report no declarations of interest., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Sub-Saharan Africa faces high rates of maternal mortality and there is an urgent need to reduce this. Shortfalls in access to safe surgery and anaesthetic care result in avoidable maternal death. Providing quality training to anaesthesia providers is of key importance to reduce mortality. This mixed-methods prospective study incorporated workplace observations of anaesthesia for Caesarean section, a paper-based questionnaire and semi-structured, face-to-face interviews in Felege Hiwot Referral Hospital in Ethiopia.A total of 67 Caesarean section cases under spinal anaesthesia provided by 12 non-physician anaesthetists were observed and a 92% ( n  = 11) response rate to questionnaires obtained. Deficiencies were observed in communication, pre-operative assessment, spinal height evaluation and application of lateral tilt, while interviews revealed anaesthesia provider perceptions of hierarchy within the surgical team and deficiency in anticipation of potential complications. This study suggests that focusing on communication and anticipation of complications could aid providers in preventing and preparing for complications.

In this prospective trial, we investigate the effectiveness of maternal Body Roundness Index in predicting the spread of spinal anaesthesia and vasopressor requirement in parturients receiving spinal anaesthesia during the elective caesarean section. We prospectively enrolled 175 parturients. Spinal anaesthesia performed with 10 mg 0.5% hyperbaric bupivacaine at the L3-L4 intervertebral space and the optimal cut-off points of the BRI evaluated as 6.59 by receiver operating characteristic analysis calculating area under the curve. Parturients were divided into two groups with BRI <6.59 and BRI ≥6.59 for analyses. Multivariate logistic regression analysis was used to test for a relationship between variables and maximum sensory block level and vasopressor requirement. BRI was found as an independent risk factor associated with maximum sensory block level (OR = 1.378, 95% CI: 1.125-1.687, p  = 0.002). Hypotension and bradycardia events after spinal anaesthesia was not associated with BRI and other variables. The present study indicates that BRI was a practical tool to predict spinal drug distribution in term parturients undergoing caesarean delivery.Impact statement What is already known on this subject? Spinal anaesthesia is a commonly used anaesthetic technique for the caesarean section. However, the spinal drug distribution is highly unpredictable. Anthropometric variables may predict the intrathecal drug distribution in parturients. Body Roundness Index (BRI) captures body circumference regarding height to predict body fat percentage, consider the shape of the human body as an ellipse. An ellipsoid body shape might affect the spread of spinal anaesthesia. What do the results of this study add? Our results show that the BRI was as an independent risk factor associated with maximum sensory block level in term parturients undergoing caesarean delivery. What are the implications of these findings for future clinical practice and/or further research? A future study would present the possibility to design a formula for the exact amount of local anaesthetic to be used in spinal anaesthesia with the aid of maternal BRI.

Background We examined the influence of companionship and the use of complementary therapies on adverse outcomes in parturients under regional analgesia. Methods This study is a single-center retrospective cohort of 986 term pregnant women, and it was based on data from medical records (hospitalization period: November 2012-November 2018). The women were in the active phase of labor under regional analgesia. A statistical program was used to search for an association between companionship and the use of complementary therapies with sample data. Bi- and multivariate logistic regressions based on significant associations were used to analyze the potential intervening variables in the adverse outcomes. Results Models were constructed for each of the maternal adverse outcomes. Childbirth complications were significantly associated with complementary therapies [adjusted odds ratio (AOR) = 0.42; 95% confidence interval (CI) = 0.28-0.63; P < 0.001] and companionship (AOR = 0.36; 95% CI = 0.22-0.57; P < 0.001). Prolonged maternal hospitalization was significantly associated with companionship (AOR = 0.57; 95% CI = 0.36-0.92; P < 0.05). Unplanned cesarean section showed a significant association with complementary therapies (AOR = 0.05; 95% CI = 0.01-0.47; P < 0.01). Conclusion The likelihood of childbirth complications and prolonged maternal hospitalization is reduced by companionship, whereas the likelihood of childbirth complications and cesarean section rates is reduced by the use of complementary therapies.

Background: Non-elective caesarean sections may be classified using a three-colour coding system, from code-green caesarean section corresponding to non-urgent delivery (no maternal of foetal compromise) to code-red caesarean section corresponding to emergency caesarean section due to immediate life-threatening maternal or foetal situations. Decision-to-delivery interval≤15min has been advocated in France for code-red caesarean section. This retrospective cohort study aimed to assess the decision-to-delivery interval and the neonatal outcomes according to the anaesthetic technique performed for code red caesarean section in a French tertiary care obstetric unit., Methods: All women undergoing code-red caesarean section between January 2013 and December 2015 were included. Demographic characteristics and anaesthetic, obstetrical and neonatal outcomes were collected from the patient's electronic medical records., Results: Among 194 code-red caesarean sections analysed, 127 (65%) were performed under epidural anaesthesia and 67 (35%) under primary general anaesthesia. The median decision-to-delivery interval was 10 [8-12.5] min, and the interval was≤15min in 174 (90%) women. Effective epidural top-up and epidural top-up requiring supplemental sedation were associated with the shortest decision-to-delivery interval. Primary general anaesthesia was independently associated with depressed 5minutes Apgar score., Conclusion: The decision-to-delivery interval was≤15min in most women, suggesting that optimised organisation ensures short decision-to-delivery interval independently of the anaesthetic technique performed. As general anaesthesia was associated with worse neonatal outcomes, our results support the early insertion of an epidural catheter whenever there is any potential concern that an emergency caesarean section may be required., (Copyright © 2019 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)

Objective: Assess whether the universalization of epidural analgesia supplied in hospitals of the Andalusia Public Health Service (SSPA) has ended up with the inequalities shown in previous studies regarding to their demand: the percentage of women who rejected epidural analgesia was higher among the users having low educational level, lower income and working as housekeeper., Method: The data are based on satisfaction surveys conducted by the Institute for Advanced Social Studies amongst of SSPA users. This survey includes a section aimed at women attended in labor (N = 21,300). The hierarchical segmentation analysis shows which variables are the ones that discriminate most in the usage of epidural analgesia. Subsequently, through a model of binary logistic regression we analyze which socio-demographic variables are significant (2012) and how its impact is on the choice of epidural analgesia in childbirth., Results: Overall, the socio-demographic variables of the users are statistically significant in the demand or not of epidural analgesia during labor. However, the detailed analysis of the last year (2012) shows that none of the socio-demographic variables introduced in the model has a significant effect on the decision of using epidural analgesia., Conclusions: The process of universalization of epidural anesthesia in childbirth has ended with social inequalities in their use, that is, with those differences that are not due to a real choice but are induced by socio-cultural characteristics of women., (Copyright © 2018 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: This nationwide survey was conducted to provide data about the obstetric anesthesia services in Israeli labor and delivery units in 2016., Methods: Prospective survey questionnaire was emailed to obstetric anesthesia unit directors/chairperson of all 25 labor and delivery services units within the jurisdiction of the Israeli Ministry of Health., Results: The response rate was 100%. Nineteen (76%) units have dedicated anesthesiologist cover. Fifteen (60%) units offered nitrous oxide, four units (16%) offered patient-controlled intravenous fentanyl and six units (24%) offered patient-controlled intravenous remifentanil for alternative labor analgesia. The median (range) epidural rate was 60% (22-85%). The median (range) cesarean delivery rate was 20% (10-26%). Overall, general anesthesia was performed for median (range) 10% (1-25%) of cesarean deliveries. Neuraxial anesthesia was performed for 95% (40-99%) of elective and 60% (0-90%) of urgent cesarean deliveries. Intrathecal morphine was administered routinely for spinal anesthesia for post-cesarean delivery analgesia in 11 (44%) units. Nineteen (72%) units had a written aspiration prophylaxis protocol; 20 (80%) had a written labor analgesia protocol; 19 (76%) had a postdural puncture headache management protocol; 20 (80%) had a local anesthetic toxicity protocol; 24 units had Intralipid available in the unit., Conclusion: No new labor units have opened since 2005, despite huge increases in delivery volume in many units. These units manage increased numbers of epidurals and cesarean deliveries. Use of intrathecal morphine for spinal anesthesia has become more widespread. Future efforts should focus on availability of emergency equipment, separate obstetric anesthesia staffing, and establishing emergency protocols., (Copyright © 2018. Published by Elsevier Ltd.)

Objective: To evaluate if the use of lidocaine gel applied to the cervix prior to manual vacuum aspiration (MVA) in addition to paracervical blockade is useful in reducing the level of pain associated with the procedure., Methods: A total of 88 patients were randomized to receive either 5 mL of lidocaine gel or a placebo applied topically to the cervix 5 minutes prior to paracervical blockade. Both groups received the same drugs for pain control (tramadol hydrochloride, diazepam, and sodium diclofenac). A visual analogue scale (VAS) was used for evaluation of pain intensity at two times: 2 minutes before the blockade (directly after tenaculum clamping of the anterior aspect of the cervix) and after MVA of the uterine cavity., Results: There was a statistically significant difference in pain intensity between the arms of the study. At the first evaluation time (cervical clamping), VAS pain score for the placebo group (control) was 3.6 (2.1) and that for the lidocaine gel group (case) was 1.2 (1.4) (P < 0.01). At the second evaluation time (after manual vacuum aspiration), VAS pain score perceived by the control group was 5.3 (2.5) and that for the case group was 3.1 (1.9) (P < 0.01). The use of lidocaine gel was not associated with any adverse effects of interest., Conclusion: The use of a topical lidocaine gel plus paracervical blockade was effective in reducing the intensity of pain associated with MVA when compared to paracervical blockade alone., (Copyright © 2018 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Background: Guidelines for obstetric anesthesia recommend neuraxial anesthesia (i.e., spinal or epidural block) for cesarean delivery in most patients. Little is known about the association of anesthesiologist specialization in obstetric anesthesia with a patient's likelihood of receiving general anesthesia. The authors conducted a retrospective cohort study to compare utilization of general anesthesia for cesarean delivery among patients treated by generalist versus obstetric-specialized anesthesiologists., Methods: The authors studied patients undergoing cesarean delivery for live singleton pregnancies from 2013 through 2017 at one academic medical center. Data were extracted from the electronic medical record. The authors estimated the association of anesthesiologist specialization in obstetric anesthesia with the odds of receiving general anesthesia for cesarean delivery., Results: Of the cesarean deliveries in our sample, 2,649 of 4,052 (65.4%) were performed by obstetric-specialized anesthesiologists, and 1,403 of 4,052 (34.6%) by generalists. Use of general anesthesia differed for patients treated by specialists and generalists (7.3% vs. 12.1%; P < 0.001). After adjustment, the odds of receiving general anesthesia were lower among patients treated by obstetric-specialized anesthesiologists among all patients (adjusted odds ratio, 0.71; 95% CI, 0.55 to 0.92; P = 0.011), and in a subgroup analysis restricted to urgent or emergent cesarean deliveries (adjusted odds ratio, 0.75; 95% CI, 0.56 to 0.99; P = 0.049). There was no association between provider specialization and the odds of receiving general anesthesia in a subgroup analysis restricted to evening or weekend deliveries (adjusted odds ratio, 0.76; 95% CI, 0.56 to 1.03; P = 0.085)., Conclusions: Treatment by an obstetric anesthesiologist was associated with lower odds of receiving general anesthesia for cesarean delivery; however, this finding did not persist in a subgroup analysis restricted to evening and weekend deliveries.

Objectives: To describe trends in caesarean sections and facilities performing caesareans over time in Tanzania and examine the readiness of such facilities in terms of infrastructure, equipment and staffing., Design: Nationally representative, repeated cross-sectional surveys of women and health facilities., Setting: Tanzania., Participants: Women of reproductive age and health facility staff., Main Outcome Measures: Population-based caesarean rate, absolute annual number of caesareans, percentage of facilities reporting to perform caesareans and three readiness indicators for safe caesarean care: availability of consistent electricity, 24 hour schedule for caesarean and anaesthesia providers, and availability of all general anaesthesia equipment., Results: The caesarean rate in Tanzania increased threefold from 2% in 1996 to 6% in 2015-16, while the total number of births increased by 60%. As a result, the absolute number of caesareans increased almost fivefold to 120 000 caesareans per year. The main mechanism sustaining the increase in caesareans was the doubling of median caesarean volume among public hospitals, from 17 caesareans per month in 2006 to 35 in 2014-15. The number of facilities performing caesareans increased only modestly over the same period. Less than half (43%) of caesareans in Tanzania in 2014-15 were performed in facilities meeting the three readiness indicators. Consistent electricity was widely available, and 24 hour schedules for caesarean and (less systematically) anaesthesia providers were observed in most facilities; however, the availability of all general anaesthesia equipment was the least commonly reported indicator, present in only 44% of all facilities (34% of public hospitals)., Conclusions: Given the rising trend in numbers of caesareans, urgent improvements in the availability of general anaesthesia equipment and trained anaesthesia staff should be made to ensure the safety of caesareans. Initial efforts should focus on improving anaesthesia provision in public and faith-based organisation hospitals, which together perform more than 90% of all caesareans in Tanzania., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: This descriptive survey was to evaluate the use of regional anesthesia in obstetrics in Greek public hospitals., Methods: The survey was conducted between March and August 2016. A structured questionnaire was sent to 50 anesthesia departments in Greek public hospitals with obstetric units., Results: The response rate was 94%. Data corresponding to 9475 cesarean and 8155 vaginal deliveries were collected. Regional anesthesia was used in 69.2% of all cesareans, with single shot spinal being the most popular (44.3% of all cesareans). Combined spinal-epidural anesthesia was used in 18.1% of all cesareans (35.1% in hospitals of Athens versus 7.9% outside Athens, p<0.001). Post-cesarean analgesia was applied with simple analgesics and systematic opioids (78.6%). Long-acting spinal opioids were rarely used (4.4% of spinal and spinal/epidurals). Labor epidural analgesia was applied in 19.1% of all vaginal deliveries (30.3% in Athens versus 13.1% outside Athens, p<0.001). Paracetamol and pethidine represented the standard labor analgesics in 48.9% and 55.3% of all hospitals. Intravenous remifentanil was used in 10.6% of hospitals (50% in Athens versus 2.5% outside Athens, p=0.002). In 48.9% of hospitals, mainly outside Athens, the anesthesiologists did not get involved in labor analgesia., Conclusion: Regional anesthesia is the most common practice for cesareans in Greek public hospitals; however, the percentage of general anesthesia remains high. In addition, the use of labor epidural analgesia is limited in hospitals outside Athens.

We conducted a 5-year retrospective cohort study on women undergoing caesarean section to investigate factors influencing the operating room-to-incision interval. Time-to-event analysis was performed for category-1 caesarean section using a Cox proportional hazards regression model. Covariates included: anaesthetic technique; body mass index; age; parity; time of delivery; and gestational age. Binary logistic regression was performed for 5-min Apgar score ≥ 7. There were 677 women who underwent category-1 caesarean section and who met the entry criteria. Unadjusted median (IQR [range]) operating room-to-incision intervals were: epidural top-up 11 (7-17 [0-87]) min; general anaesthesia 6 (4-11 [0-69]) min; spinal 13 (10-20 [0-83]) min; and combined spinal-epidural 24 (13-35 [0-75]) min. Cox regression showed general anaesthesia to be the most rapid method with a hazard ratio (95%CI) of 1.97 (1.60-2.44; p < 0.0001), followed by epidural top-up (reference group), spinal anaesthesia 0.79 (0.65-0.96; p = 0.02) and combined spinal-epidural 0.48 (0.35-0.67; p < 0.0001). Underweight and overweight body mass indexes were associated with longer operating room-to-incision intervals. General anaesthesia was associated with fewer 5-min Apgar scores ≥ 7 with an odds ratio (95%CI) of 0.28 (0.11-0.68; p < 0.01). There was no difference in neonatal outcomes between the first and fifth quintiles for operating room-to-incision intervals. General anaesthesia is associated with the most rapid operating room-to-incision interval for category-1 caesarean section, but is also associated with worse short term neonatal outcomes. Longer operating room-to-incision intervals were not associated with worse neonatal outcomes., (© 2018 The Association of Anaesthetists of Great Britain and Ireland.)

Background: UK national anaesthetic activity was studied in 2013 but weekend working was not examined. Understanding changes since 2013 in workload and manpower distribution, including weekends, would be of value in workforce planning., Methods: We performed an observational survey of NHS hospitals' anaesthetic practice in October 2016 as part of the 6th National Audit Project of the Royal College of Anaesthetists (NAP6). All cases cared for by an anaesthetist during the study period were included. Patient characteristics and details of anaesthetic conduct were collected by local anaesthetists., Results: Responses were received from 342/356 (96%) hospitals. In total, 15 942 cases were reported, equating to an annual anaesthetic workload of ≈3.13 million cases. Approximately 95% (9888/10 452) of elective and 72% (3184/4392) of emergency work was performed on weekdays and 89% (14 145/15 942) of activity was led by senior (consultant or career grade) anaesthetists and 1.1% (180/15942) by those with <2 yr anaesthetic experience. During weekends case urgency increased, the proportion of healthy patients reduced and case mix changed. Cases led by senior anaesthetists fell to 80% (947/1177) on Saturday and 66% (342/791) on Sunday. Senior involvement in obstetric anaesthetic activity was 69% (628/911) during the week and 45% (182/402) at weekends, compared with 93% (791/847) in emergency orthopaedic procedures during the week and 89% (285/321) at weekends. Since 2013, the proportion of obese patients, elective weekend working, and depth of anaesthesia monitoring has increased [12% (1464/12 213) vs 2.8%], but neuromuscular monitoring has not [37% (2032/5532) vs 38% of paralysed cases]., Conclusions: Senior clinicians deliver most UK anaesthesia care, including at weekends. Our findings are important for any planned workforce reorganisation to rationalise 7-day working., (Copyright © 2018 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Introduction: Accurately predicting cesarean delivery case duration is an integral component of designing appropriate workflow protocols and ensuring adequate provider availability. Our primary objective was to describe the variability of case duration, based on factors that we hypothesized would be influential, such as hospital facility type, United States region, time of day, case volume, and patient and provider characteristics., Methods: We analyzed hospital-, patient-, and provider-level variables from the National Anesthesia Clinical Outcomes Registry, a voluntary registry created to share anesthesia-related data and outcomes. Multivariable linear regression was performed to assess the association of these variables to case duration., Results: A total of 205332 cases were included in the final analysis. The majority of these cases came from medium-sized community hospitals (50.8%). Mean and median case duration were 115 and 79 minutes, respectively. Mean duration was longest for cases performed at university hospitals (143 min, standard deviation 136 min). Case duration varied in clinically meaningful ways based on hospital facility type, United States region, presence of a Certified Registered Nurse Anesthetist, and anesthesia type. Differences were not clinically significant with respect to other variables studied., Conclusion: This study analyzed national cesarean delivery data and determined factors associated with cesarean delivery duration. We showed that case durations varied in meaningful ways according to facility type, United States region, presence of a Certified Registered Nurse Anesthetist, and anesthesia type. Our work contributes to a small but growing body of research on optimal staffing models for anesthesia practices., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Knowledge of hospital-specific average cesarean delivery operative times, and factors influencing length of surgery, can serve as a guide for anesthesiologists when choosing the optimal anesthetic technique. The aim of this study was to determine operative times and the factors influencing those times for cesarean delivery., Methods: We conducted a retrospective review of all 1348 cesarean deliveries performed at an academic hospital in 2011. The primary outcome was mean operative time for first, second, third and fourth or more cesarean deliveries. The secondary goal was to identify factors influencing operative time. Variables included age, body mass index, previous surgery, gestational age, urgency of cesarean delivery, anesthesia type, surgeon's seniority, layers closed, and performance of tubal ligation., Results: Mean (standard deviation) operative times for first (n=857), second (n=353), third (n=108) and fourth or more (n=30) cesarean deliveries were 56 (19), 60 (19), 69 (28) and 82 (31) minutes, respectively (P <0.0001, all groups different). Emergency status of the case and later gestational age were associated with shorter operative times. Higher body mass index, a less senior surgeon, the number of layers closed, and tubal ligation, increased operative times. These factors accounted for 18% of the variability., Conclusions: Third and fourth cesarean delivery or the presence of other factors that could increase operative time may warrant catheter-based anesthetic techniques or the addition of adjunctive medications to prolong spinal anesthetic block. Institutional and individual surgeon factors may play an even more important role in determining surgical time., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

The primary aim of this systematic review was to assess the effect on neonatal outcome of pharmacological interventions used for attenuation of the haemodynamic response to tracheal intubation in patients undergoing caesarean section under general anaesthesia. A systematic search of randomised controlled trials from 1990 to 2015 was conducted. The primary outcome measure was the Apgar score at five minutes and secondary outcomes were umbilical arterial blood gas parameters and neurological adaptive capacity scores. Twenty-seven randomised controlled trials (1,689 patients) were included in the qualitative synthesis. Only five studies using opioids (383 patients) and five studies using non-opioid analgesics (358 patients) were subjected to meta-analysis. The Apgar score at five minutes was significantly lower in neonates of opioid-treated mothers (mean difference: -0.29, 95% confidence interval -0.56 to -0.02, P -value=0.03) compared to mothers in the control group; the umbilical arterial pH was lower and there was a higher requirement for tactile stimulation in neonates. No difference was seen in Apgar scores of neonates of mothers administered non-opioid analgesics compared to placebo. No difference was observed in other parameters between opioid- or non-opioid-treated mothers. This review suggests that opioid interventions for attenuation of the haemodynamic response to tracheal intubation in pregnant patients under general anaesthesia affect neonatal Apgar scores at five minutes in neonates but the difference did not appear to be clinically meaningful. We were unable to demonstrate any difference in safety.

Shoulder dystocia is a rare but severe birth trauma where the neonate's shoulders fail to deliver after delivery of the head. Failure to deliver the shoulders quickly can lead to severe, long-term injury to the infant, including nerve injury, skeletal fractures, and potentially death. This observational study examined shoulder dystocia risk factors by race and ethnicity using a sample of 19,236 pregnant women who presented for labor and delivery from July 1, 2010 until June 30, 2013 at five locations. Multivariate analyses were used to identify risk factors associated with shoulder dystocia occurrence in racial/ethnic groups with high incidence rates. For White non-Hispanic mothers, the strongest risk factors were delivering past 40 weeks' gestation (odds ratio [OR] = 2.4; 95% confidence interval [CI] = 1.5, 3.9; p < .01) and use of epidural anesthesia during delivery (OR = 4.4; 95% CI = 3.0, 6.4; p < .01). Among Black non-Hispanic mothers, the risk factors with the greatest impact were use of epidural (OR = 5.3; 95% CI = 3.2, 8.7; p < .01) and having gestational diabetes and controlling the condition with insulin (OR = 4.6; 95% CI = 1.5, 13.8; p < .01). Additionally, among Hispanic mothers, having Spanish as primary language increased shoulder dystocia likelihood compared to those who did not cite it as their primary language (OR = 2.3; 95% CI = 1.1, 4.6; p < .05). This study provides evidence that risk factors for a labor and delivery condition can vary significantly across racial and ethnic subgroups. These differences emphasize the importance of evaluating risk by population subgroups and might provide a basis for labor and delivery clinicians to enhance personalized medicine to reduce adverse events.

Background: Socioeconomic deprivation is associated with reduced use of antenatal resources and poor maternal outcomes with pregnancy. Research examining the association between socioeconomic deprivation and use of obstetric anesthesia care in a country providing universal health coverage is scarce. We hypothesized that in a country providing universal health coverage, France, socioeconomic deprivation is not associated with reduced use of anesthetic care during pregnancy and delivery. This study aimed to examine the association between socioeconomic deprivation and (1) completion of a mandatory preanesthetic evaluation during pregnancy and (2) use of neuraxial analgesia during labor., Methods: Data were from a cohort of 10,419 women who delivered between 2010 and 2011 in 4 public teaching hospitals in Paris. We used a deprivation index that included 4 criteria: social isolation, poor housing condition, no work-related household income, and state-funded health care insurance. Socioeconomic deprivation was defined as a deprivation index greater than 1. Preanesthetic evaluation was considered completed if performed more than 48 hours before delivery. The association between socioeconomic deprivation and completion of the preanesthetic evaluation and use of neuraxial labor analgesia was assessed by multivariable logistic regression adjusting for education level, country of birth, and maternal and pregnancy characteristics., Results: Preanesthetic evaluation was completed for 8142 of the 8624 women (94.4%) analyzed and neuraxial labor analgesia was used by 6258 of the 6834 women analyzed (91.6%). After adjustment, socioeconomic deprivation was associated with reduced probability of completed preanesthetic evaluation (adjusted odds ratio 0.88 [95% confidence interval, 0.79-0.98]; P = .027) but not use of neuraxial labor analgesia (adjusted odds ratio 0.97 [95% confidence interval, 0.87-1.07]; P = .540)., Conclusions: In a country providing universal health care coverage, women who were socioeconomically deprived showed reduced completion of preanesthetic evaluation during pregnancy but not reduced use of neuraxial labor analgesia. Interventions should be targeted to socioeconomically deprived women to increase the completion of the preanesthetic evaluation.

Racial and ethnic disparities are prevalent within healthcare and have persisted despite advances in medicine and public health. Disparities have been described in the use of neuraxial labor analgesia, with minority women being less likely to use neuraxial labor analgesia than non-minority white women. Minority women are also more likely to have a general anesthetic for cesarean delivery than non-minority women. The origins of these disparities are likely multi-factorial, with patient-, provider-, and systems-level contributors. The purpose of this article is to give an overview of disparities in obstetric anesthesia., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Neuraxial anaesthesia is widely used in obstetrics and neurological complications are rare. However, when they occur, subsequent investigation and management are time-critical and correlate with the extent of neurological recovery. The Third National Audit Project recommended the implementation of guidelines in obstetric epidural management, including advice on monitoring for early signs of problems and acting upon concerns. However, no national guideline exists for postoperative management in the obstetric population. We conducted a national survey of monitoring after obstetric neuraxial blockade and the management of an abnormally prolonged block. We received responses from 112/189 (59.3%) obstetric anaesthetic leads invited to participate. We determined that post-neuraxial blockade monitoring in the UK is highly variable: only 63/112 (56.3%) respondents' units had a monitoring policy in place, although most of these did not undertake formal neurological monitoring, and a range of different monitoring methods and schedules were employed. In 12/63 (19%) local policies, the first review of neurology was performed at the standard postoperative visit the following day, and 66/112 (58.9%) units had no protocol in place to address emergency management of abnormally prolonged neuraxial blockade. Where a policy was in place, the initial recommended action and the type of imaging used were variable., (© 2017 The Association of Anaesthetists of Great Britain and Ireland.)

Objective: This study is aiming to determine an actual incidence and characteristics of complications in cesarean section for severe pre-eclampsia (PE) by analysis of a large cohort from a single tertiary care center according to two choices of anesthesia., Methods: Electronic medical records of pregnant women complicated with severe PE delivered by cesarean section from January 2002 to December 2011 were retrospectively reviewed. Medical records of their corresponding neonates were also identified and reviewed., Results: A total of 701 women and 740 neonates (28 twin pairs) were identified. Anesthetic techniques were spinal anesthesia (SA) (88%) and general anesthesia (GA) (12%). Total maternal and neonatal deaths were 0.3% and 1.2%, respectively. Patients in GA group had a higher incidence of coagulopathy, immediate postpartum hemorrhage, intensive care unit admission, renal failure, respiratory complications, and death (p < 0.05). Neonates born from women in GA group had a higher incidence of lower birth weight, birth asphyxia, prematurity, neonatal intensive care admission, respiratory complications, and death (p < 0.05)., Conclusion: Spinal anesthesia can be safely administered to severely pre-eclamptic parturients undergoing cesarean section. General anesthesia is associated with more untoward outcomes, as it has been chosen in patients with more severity of the disease.

Background: Racial and ethnic disparities have been identified in the provision of neuraxial labor analgesia. These disparities may exist in other key aspects of obstetric anesthesia care. We sought to determine whether racial/ethnic disparities exist in mode of anesthesia for cesarean delivery (CD)., Methods: Women who underwent CD between 1999 and 2002 at 19 different obstetric centers in the United States were identified from the Maternal-Fetal Medicine Units Network Cesarean Registry. Race/ethnicity was categorized as: Caucasian, African American, Hispanic, and Non-Hispanic Others (NHOs). Mode of anesthesia was classified as neuraxial anesthesia (spinal, epidural, or combined spinal-epidural anesthesia) or general anesthesia. To account for obstetric and non-obstetric covariates that may have influenced mode of anesthesia, multiple logistic regression analyses were performed by using sequential sets of covariates., Results: The study cohort comprised 50,974 women who underwent CD. Rates of general anesthesia among racial/ethnic groups were as follows: 5.2% for Caucasians, 11.3% for African Americans, 5.8% for Hispanics, and 6.6% for NHOs. After adjustment for obstetric and non-obstetric covariates, African Americans had the highest odds of receiving general anesthesia compared with Caucasians (adjusted odds ratio [aOR] = 1.7; 95% confidence interval [CI], 1.5-1.8; P < 0.001). The odds of receiving general anesthesia were also higher among Hispanics (aOR = 1.1; 95% CI, 1.0-1.3; P = 0.02) and NHOs (aOR = 1.2; 95% CI, 1.0-1.4; P = 0.03) compared with Caucasians, respectively. In our sensitivity analysis, we reconstructed the models after excluding women who underwent neuraxial anesthesia before general anesthesia. The adjusted odds of receiving general anesthesia were similar to those in the main analysis: African Americans (aOR = 1.7; 95% CI, 1.5-1.9; P < 0.001); Hispanics (aOR = 1.2; 95% CI, 1.1-1.4; P = 0.006); and NHOs (aOR = 1.2; 95% CI, 1.0-1.5; P = 0.05)., Conclusions: Based on data from the Cesarean Registry, African American women had the highest odds of undergoing general anesthesia for CD compared with Caucasian women. It is uncertain whether this disparity exists in current obstetric practice.

We assessed the practice of obstetric anesthesia in Flanders through an on-line enquiry form and investigated the advancements by comparing the results with those of the 2004 survey. 54 (86%) structured forms were completed, representative for 94% of the accredited maternity beds in Flanders. Obstetric anesthesia is provided in all Flemish acute hospitals and 7/10 deliveries are performed nowadays with neuraxial analgesia. For labor analgesia, classical epidural remains the main neuraxial technique (62%) whereas CSE is used as default technique in 17% of the hospitals and upon indication in 21%. In half of the departments a test dose is used to validate the correct placement of the catheter, with lidocaine as the most (68%) commonly used test drug; this practice is comparable to 10 years ago. Ropivacaine (84%) with or without sufentanil is typically used as loading dose and ropivacaine with sufentanil (83%) to maintain the epidural analgesia. Patient-controlled epidural analgesia is the preferred maintenance mode (76%) for labor analgesia. CSE with hyperbaric bupivacaine and sufentanil is the most used anesthesia protocol when caesarean section is required (47%). There is no clear preference for postoperative analgesia after cesarean section as both epidural/regional and parenteral/per os analgesia regimens are almost equally used in Flemish obstetric care.

Objective: Measures of maternal mortality and severe maternal morbidity have risen in the United States, sparking national interest regarding hospitals' ability to provide maternal risk-appropriate care. We examined the extent to which hospitals could be classified by increasingly sophisticated maternal levels of care., Study Design: We performed a cross-sectional survey to identify hospital-specific resources and classify hospitals by criteria for basic, intermediate, and regional maternal levels of care in all nonmilitary childbirth hospitals in California. We measured hospital compliance with maternal level of care criteria that were produced via consensus based on professional standards at 2 regional summits funded by the March of Dimes through a cooperative agreement with the Community Perinatal Network in 2007 (California Perinatal Summit on Risk-Appropriate Care)., Results: The response rate was 96% (239 of 248 hospitals). Only 82 hospitals (34%) were classifiable under these criteria (35 basic, 42 intermediate, and 5 regional) because most (157 [66%]) did not meet the required set of basic criteria. The unmet criteria preventing assignment into the basic category included the ability to perform a cesarean delivery within 30 minutes 100% of the time (only 64% met), pediatrician availability day and night (only 56% met), and radiology department ultrasound capability within 12 hours (only 83% met). Only 29 of classified hospitals (35%) had a nursery or neonatal intensive care unit level that matched the maternal level of care, and for most remaining hospitals (52 of 53), the neonatal intensive care unit level was higher than the maternal care level., Conclusion: Childbirth services varied widely across California hospitals, and most hospitals did not fit easily into proposed levels. Cognizance of this existing variation is critical to determining the optimal configuration of services for basic, intermediate, and regional maternal levels of care., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: The objective of the study was to describe the resources and activities associated with childbirth services., Study Design: We adapted models for assessing the quality of healthcare to generate a conceptual framework hypothesizing that childbirth hospital resources and activities contributed to maternal and neonatal outcomes. We used this framework to guide development of a survey, which we administered by telephone to hospital labor and delivery nurse managers in California. We describe the findings by hospital type (ie, integrated delivery system [IDS], teaching, and other [community] hospitals)., Results: Of 248 nonmilitary childbirth hospitals in California, 239 (96%)responded; 187 community, 27 teaching, and 25 IDS hospitals reported. The context of services varied across hospital types, with community hospitals more likely to have for-profit ownership, be in a rural or isolated location, and have fewer annual deliveries per hospital. Results included the findings of the following: (1) 24 hour anesthesia availability in 50% of community vs 100% of IDS and teaching hospitals (P < .001); (2) 24 hour in-house labor and delivery physician coverage in 5% of community vs 100% of IDS and 48% of teaching hospitals (P < .001); (3) 24 hour blood bank availability in 88% of community vs 96% of IDS and 100% of teaching hospitals (P = .092); (4) adult subspecialty intensive care unit availability in 33% of community vs 36% of IDS and 82% of teaching hospitals (P < .001); (5) ability to perform emergency cesarean delivery in 30 minutes 100% of the time in 56% of community vs 100% of IDS and 85% of teaching hospitals (P < .001); (6) pediatric care available both day and night in 54% of community vs 63% of IDS vs 76% of teaching hospitals (P = .087); and (7) no neonatal intensive care unit in 44% of community vs 12% of IDS and 4% of teaching hospitals (P < .001)., Conclusion: Childbirth services varied widely across California hospitals. Cognizance of this variation and linkage of these data to childbirth outcomes should assist in the identification of key resources and activities that optimize the hospital environment for pregnant women and set the groundwork for identifying criteria for the provision of maternal risk-appropriate care., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Unlabelled: Anaesthesia has evolved in France since the last epidemiologic survey in 1996. The national database program for medical information systems (the PMSI) can be used to track specific knowledge concerning anaesthesia for a selected period of time. The goal of this study was to perform a contemporary epidemiological description of anaesthesia in France for the year 2010., Methods: The data concerning private or public hospital stays were collected from the national PMSI database. All surgical/medical institutions performing anaesthesia in France and French Overseas Departments and Territories were queried concerning the number of anaesthesias, patient age, sex ratios, institution characteristics, hospitalization types, the duration of hospital stays, and the surgical procedures performed., Results: In 2010, the number of anaesthesia procedures performed was 11,323,630 during 8,568,630 hospital stays. We found that 9,544,326 (84.3%) anaesthetic procedures were performed in adults (> 18 years of age; excluding childbirth), 845,568 (7.5%) were related to childbirth and 933,736 (8.2%) were acts in children (up to 18 years of age). The mean duration of hospital stay was 5.7±8.2 days. 56.5% of adults and 39.5% of children were managed as inpatient hospital stays. The male/female sex ratio and mean age were 42/58 and 54±19 years, respectively. In adults, anaesthesia was predominantly performed for abdominal surgery (24.5%), orthopaedics (16.7%), gynaecology (10.3%), ophthalmology (9.7%) and vascular surgeries (7.1%). For paediatric populations, the main surgical activities were Ear-Nose-Throat surgery (43.1%), orthopaedic surgery (15.1%) and urological surgeries (12.8%)., Discussion: The number of anaesthesias performed in France has dramatically increased (42.7%) since the last major epidemiological survey. Anaesthesia in the 21th century has been adapted to associated demographic changes: an older population with more comorbidities and fewer in-hospital procedures., (Copyright © 2015 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)

Background: The rate of anesthesia-related adverse events (ARAEs) is recommended for monitoring patient safety across hospitals. To ensure comparability, it is adjusted for patients' characteristics with logistic models (i.e., risk adjustment). The rate adjusted for patient-level characteristics and hospital affiliation through multilevel modeling is suggested as a better metric. This study aims to assess a multilevel model-based rate of ARAEs., Methods: Data were obtained from the State Inpatient Database for New York 2008-2011. Discharge records for labor and delivery and ARAEs were identified with International Classification of Diseases, Ninth Revision, Clinical Modification codes. The rate of ARAEs for each hospital during 2008-2009 was calculated using both the multilevel and the logistic modeling approaches. Performance of the two methods was assessed with (1) interhospital variability measured by the SD of the rates; (2) reclassification of hospitals; and (3) prediction of hospital performance in 2010-2011. Rankability of each hospital was assessed with the multilevel model., Results: The study involved 466,442 discharge records in 2008-2009 from 144 hospitals. The overall observed rate of ARAEs in 2008-2009 was 4.62 per 1,000 discharges [95% CI, 4.43 to 4.82]. Compared with risk adjustment, multilevel modeling decreased SD of ARAE rates from 4.7 to 1.3 across hospitals, reduced the proportion of hospitals classified as good performers from 18% to 10%, and performed similarly well in predicting future ARAE rates. Twenty-six hospitals (18%) were nonrankable due to inadequate reliability., Conclusion: The multilevel modeling approach could be used as an alternative to risk adjustment in monitoring obstetric anesthesia safety across hospitals.

The surgical and anaesthesia needs of low-income countries are mostly unknown due to the lack of data on surgical infrastructure and human resources. The goal of this study is to assess the surgical and anaesthesia capacity in Guyana. A survey tool adapted from the WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care was used to survey nine regional and district hospitals within the Ministry of Health system in Guyana. In nine hospitals across Guyana, there were an average of 0.7 obstetricians/gynaecologists, 3.5 non-OB surgeons, and 1 anaesthesiologist per hospital. District and regional hospitals performed an annual total of 1520 and 10,340 surgical cases, respectively. All but 2 district hospitals reported the ability to perform surgery. An average hospital has two operating rooms; 6 out of 9 hospitals reported routine medication shortages, and 4 out of 9 hospitals reported routine water or electricity shortages. Amongst the three regional hospitals, 16.1% of pregnancies resulted in Caesarean section. Surgical capacity varies by hospital type, with district hospitals having the least surgical capacity and surgical volume. District level hospitals routinely do not perform surgery due to lack of basic infrastructure and human resources., (Copyright © 2014 Ministry of Health, Saudi Arabia. Published by Elsevier Ltd. All rights reserved.)

Introduction: A previous meta-analysis reported lower umbilical artery pH with spinal anesthesia for cesarean delivery compared to general or epidural anesthesia. Ephedrine was used in the majority of studies. The objective of this study was to evaluate the effect of anesthetic technique on neonatal acid-base status now that phenylephrine has replaced ephedrine in our institution., Methods: We retrospectively reviewed our database to identify patients who underwent cesarean delivery and had umbilical artery pH available. We decided a priori to test separately cases where cesarean delivery was performed emergently (category I and II) or non-emergently (category III and IV). Multivariable models were constructed to detect significant predictors of lower umbilical artery pH., Results: One thousand sixty-four cases were included (647 emergent, 417 non emergent). In emergent cesarean delivery, anesthesia type was a significant predictor of lower umbilical artery pH (P <0.0001) with the pairwise comparisons showing lower neonatal umbilical artery pH [mean (95% CI)] with general anesthesia [7.16 (7.13, 7.19)] compared with spinal anesthesia [7.24 (7.22, 7.25)] and epidural anesthesia [7.23 (7.21, 7.24)], with no difference between spinal and epidural anesthesia. When excluding cases where general anesthesia was chosen due to insufficient time to place a neuraxial block or dose an existing epidural catheter, anesthesia type was not a predictor of lower umbilical artery pH. Anesthetic technique was not a predictor of lower umbilical artery pH in non-emergent cases., Conclusions: Spinal anesthesia was not associated with lower umbilical artery pH compared to other types of anesthesia. This might be due to the use of phenylephrine in our practice., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: The Obstetric Anaesthetists' Association (OAA) has facilitated national surveys in obstetric anaesthesia since 1998. We wanted to examine trends in OAA-approved surveys since this time., Methods: OAA-approved surveys performed between January 1998 and December 2012 were examined for the year they were carried out, the format (postal or electronic), the target group and the response rate. We determined whether each survey was presented or published. For each survey published as a substantive paper, we identified the number of times the publication had been cited. We also surveyed lead obstetric anaesthetists and expert witnesses practising in obstetric anaesthesia on the perceived usefulness of OAA-approved surveys., Results: One hundred and thirty-five surveys approved by the OAA were carried out between 1998 and 2012. Response rates have fallen over the years, reaching a current plateau of 65%. Response rates varied with the target group. Seventy-eight percent of surveys were presented and 83% were published in some form. For surveys published as substantive papers (n=34, 25%), the median [IQR (range)] number of citations was 6 [3-11 (0-36)] per publication. Our survey of lead obstetric anaesthetists had a response rate of 62%. Those who replied rated OAA surveys a median [IQR (range)] of 6 [5-7 (1-9)] on a 0-10 scale of usefulness to their clinical practice., Conclusions: Response rates to OAA-approved surveys have declined but remain acceptable despite an increase in the number of surveys performed. Most surveys were presented or published in some form., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Objective: To evaluate the efficacy of inducing labour using a double-balloon catheter and oral misoprostol sequentially, in comparison with oral misoprostol alone., Design: A multicentre randomised controlled trial., Setting: Five hospitals in Germany., Population: A total of 326 pregnant women with an unfavourable cervix undergoing labour induction at term., Methods: Women were randomly assigned according to a computer-generated allocation sequence to sequential use of double-balloon catheter and oral misoprostol (study group) or oral misoprostol alone (control group). In the study group, the double-balloon catheter was used the first day before starting oral misoprostol the second day., Main Outcome Measures: The primary outcome measure was the induction-to-delivery interval, and a further outcome parameter was delivery within 48 hours., Results: The median times for induction of labour until delivery were 32.4 hours in the study group and 22.5 hours in the control group (P = 0.004). This difference was not seen when evaluating according to parity (nulliparous, P = 0.19; parous, P = 0.06). The rate of vaginal delivery within 48 hours did not differ between both groups. The number of applications of misoprostol (two versus three, P < 0.001) and the dose of misoprostol used was lower in the study group (100 versus 200 μg, P < 0.001). In the study group, there were more Apgar scores of <7 at 5 minutes (8 versus 1, P = 0.04)., Conclusions: The use of a double-balloon catheter on the first day, before starting oral misoprostol on the second day, did not improve the induction to delivery interval and the rate of delivery within 48 hours, in comparison with oral misoprostol alone., (© 2014 Royal College of Obstetricians and Gynaecologists.)

Objective: To compare clinical outcomes from outpatient with inpatient cervical prostaglandin E2 ripening for low risk labour induction., Design: Randomised controlled trial., Setting: Two tertiary hospitals in Adelaide, Australia., Population: Women with uncomplicated term pregnancies, scheduled for induction of labour for reasons of post-dates or for social reasons., Methods: Eight hundred and twenty-seven women were randomised at induction decision to an outpatient or inpatient group. All women had CTG monitoring before and after vaginal PgE2 administration. The inpatient women were admitted and the outpatient group was discharged home overnight with instructions to return if labour established or rupture of membranes occurred. Next morning, outpatient women were admitted for rupture of membranes or further ripening. After membrane rupture, both groups received routine care., Main Outcome Measures: Oxytocin use, maternal and fetal outcomes, and whether planned outpatient management was achievable., Results: There were no significant differences in oxytocin use (2.5% difference, CI-4.3 to 9.4), caesarean sections (-0.59% difference, CI-6.3 to 5.1), epidural use (1.5% difference, CI-5.1 to 8.2), vaginal delivery within 24 hours (-8.2% difference, CI-17.6 to 1.3) or labour complications. More than half of the randomised women did not receive the intervention as they laboured spontaneously, or did not require ripening. The post-hoc analysis of women who received ripening also indicated no statistically significant differences in the patterns or results, with the exception of outpatient women having a longer mean length of active labour (mean difference 66 minutes, CI 4-128 minutes). Outpatient women who received ripening were diagnosed more frequently with non-reassuring CTG monitoring and hyperstimulation, with less than half of the women going home and remaining home overnight., Conclusions: This study demonstrated no clinical advantage or disadvantage in prostaglandin E2 outpatient cervical ripening. Uterine stimulation following prostaglandins may preclude a woman from going home or remaining at home overnight and may not be the best agent for outpatient ripening., (© 2014 Royal College of Obstetricians and Gynaecologists.)

Background: In resource-limited settings, severe shortages of anesthetists and anesthesiologists lead to surgical delays that increase maternal and neonatal mortality and morbidity., Objectives: To more clearly understand the individual components of the anesthesia gap pertaining to reproductive health surgeries and procedures in resource-limited settings., Search Strategy: Medline, the Cochrane Library, CINAHL, Embase, and POPLINE were systematically searched for reports published before December 31, 2013. Search terms were related to obstetric surgery, resource-limited settings, and anesthesia., Selection Criteria: Studies that addressed the use of anesthesia in reproductive procedures in resource-limited settings were included., Data Collection and Analysis: Reviewers independently evaluated the full text of identified studies, extracted information related to study objectives and conclusions, and identified the anesthesia gap., Main Results: Overall, 14 publications met the inclusion criteria. A significant lack of infrastructure, equipment and supplies, and trained personnel were identified as key factors responsible for a lack of anesthesia services., Conclusions: A shortage of trained anesthesia providers, equipment, supplies, medications, and infrastructure, along with limitations in transportation in resource-limited settings have produced a wide gap between available anesthesia services and the demand for them for reproductive health surgeries and procedures. Safe, affordable, and scalable solutions to address the anesthesia gap are urgently needed., (Copyright © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.)

Background: In 1993, Hood and Dewan published the results of a trial comparing obstetric and anesthetic outcomes of 117 morbidly obese parturients with matched controls. The authors demonstrated a higher initial epidural anesthesia failure rate, a higher cesarean delivery rate and an increased risk of obstetric complications. We replicated the previous study to provide updated information on outcomes in the morbidly obese pregnant population. We hypothesized that morbidly obese women would still have higher complication and failure rates compared to matched controls and that general anesthesia would be less commonly used than in the previous study., Methods: The medical records of 230 patients weighing >136 kg (300 pounds) were compared to matched controls: the next patient delivered by the same obstetrician with a weight <113 kg (250 pounds)., Results: The mean body mass index of the morbidly obese group was 53.4 ± 6.6 kg/m² [corrected] compared to 31.1±5.4 kg/m2 in the control group. Fifty percent of morbidly obese women required cesarean delivery compared to 32% of controls (P < 0.01). Morbidly obese patients had a longer first stage of labor (P < 0.01), larger neonates (P < 0.01), and were more likely to have a failed initial neuraxial technique for labor analgesia (P < 0.01). The need for a replacement procedure for labor was 17%, significantly less than 20 years ago when 42% of catheters in morbidly obese women failed (P < 0.01). Failure rates of neuraxial anesthesia for cesarean delivery were similar between groups. Neuraxial procedure times were greater in morbidly obese parturients (P < 0.01). Morbidly obese women were less likely to receive general anesthesia compared to 20 years ago (3% vs. 24%, P < 0.01)., Conclusions: Morbidly obese parturients are still at increased risk for antenatal comorbidities, failed labor analgesia, longer first stage of labor and operative delivery. Replacement labor epidural catheters and general anesthesia for cesarean delivery are less commonly required anesthetic techniques compared to the original study., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: Eclampsia is still associated with high maternal and perinatal and perinatal morbidity and mortality, especially in resource poor countries with limited access to perinatal and critical care facilities. The ideal method of anaesthesia for caesarean section in eclamptics is not generally agreed upon., Methods: Review of the patients' case notes as well as records of the institution's Labour Ward Theatre, Intensive Care Unit and Postnatal Ward was carried out between January 2011 and December 2012. Patients' clinical and demographic data, anaesthetic management methods, maternal and perinatal outcome measures were evaluated and analysed., Results: Ninety-nine cases of eclampsia were reviewed, of which 87 had Caesarean section. After excluding five patients who had intercurrent medical ailments, 82 patients were finally analyzed. Of these, 65 (79.3%) had spinal anaesthesia while 17 (20.7%) had general anaesthesia. Out of the 19 (23.2%) who were transferred to the intensive care unit, 12 (70.6%) had general anaesthesia while 7 (10.8%) had spinal anaesthesia. Of the 17 patients who had general anaesthesia, 10 (58.8%) were ventilated post operatively versus only 2 (3.1%) in spinal anaesthesia. Nine of the 17 general anaesthesia patients (52.9%) versus only 1 of 65 spinal anaesthesia (1.5%) died in ICU. Apgar was two fold better in the spinal anaesthesia group at 5 minutes.There was a higher risk ratio for stillbirths in the general anaesthesia patients., Conclusion: maternal and perinatal survival and well being are better in eclamptics who had spinal anaesthesia for caesarean section compared to those who had general anaesthesia.

Background: The peripartum management of anticoagulated patients poses important challenges for obstetric anesthesiologists, especially when deciding to perform neuraxial block. However, there is limited evidence evaluating anticoagulant prescribing practices and neuraxial block utilization in this setting. Our objective was to examine peripartum anticoagulant prescribing and anesthetic practices in a cohort of anticoagulated patients receiving subcutaneous enoxaparin, and subcutaneous or intravenous unfractionated heparin., Methods: We performed a retrospective study of anticoagulant prescribing patterns and anesthetic interventions among patients receiving enoxaparin and/or unfractionated heparin who delivered at a USA obstetric center over a seven-year period., Results: We identified 101 patients who received enoxaparin and/or unfractionated heparin before delivery. Thirty-nine (38.6%) patients received enoxaparin only, 41 (40.6%) patients received enoxaparin bridged to subcutaneous unfractionated heparin, 11 (10.9%) patients received enoxaparin and were converted to intravenous unfractionated heparin and 10 (9.9%) patients received only subcutaneous unfractionated heparin. The overall rate of neuraxial block utilization was 80.2%. The median [IQR] time-period between the last dose of enoxaparin and neuraxial block was significantly shorter for patients who received only enoxaparin vs. enoxaparin with subcutaneous unfractionated heparin (54h [12-192h] (n=26) vs. 216h [39-504h] (n=23), P=0.04). Among patients who received only subcutaneous unfractionated heparin, the time period between unfractionated heparin and neuraxial block was 24h [19-51h]., Conclusion: In this study, the neuraxial block rate was high among patients receiving enoxaparin and/or subcutaneous unfractionated heparin with patients undergoing relatively long periods off anticoagulation. Careful multidisciplinary planning is recommended for the peripartum management of anticoagulated pregnant patients., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: We examined the change in anesthetic practice for Caesarean section (CS) during the past decade and determined factors influencing anethesiologists' decisions., Methods: The cases were identified from data retrieved from Longitudinal Health Insurance Database released by the Taiwan National Health Research Institute in 2008. Trend analysis was performed using logistic regression models. The decision tree analysis was performed using the chi-squared automatic interaction detector method and multivariable logistic regression analysis was performed to identify predictors of general anesthesia., Results: A total of 25,606 women undergoing CS were studied. Logistic regression analyses revealed an upward trend of spinal anesthesia from 2000 to 2008 [57.8-67.5%, adjusted odds ratio (OR) = 1.06, 95% confidence interval (CI) = 1.05-1.07, P < 0.001] and a decreasing trend across time for both general and epidural anesthesia (5.5-3.9% and 36.7-28.6%; both OR < 1, both P < 0.001). Patterns of change in anesthetic practice across time for emergency and non-emergency CS were similar (all P < 0.05). Our data further demonstrated that early or threatened labor, a history of preeclampsia, antepartum hemorrhage, emergency CS, and previous CS were important predictors that influenced the anesthesiologists' choice of general anesthesia versus neuraxial anesthesia for women undergoing CS., Conclusions: Spinal anesthesia was the most common mode of anesthesia for CS deliveries in Taiwan during the past decade. Early or threatened labor, antepartum hemorrhage, emergency CS, previous CS, and preeclampsia are significant determinants of general anesthesia in CS deliveries., (© 2014 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Spinal ultrasonography provides guidance for epidural insertion in obstetric patients. The primary objective of the study was to develop a training program in spinal ultrasound for anaesthetists and to determine its effect on the skill acquisition of anaesthetists with no prior spinal ultrasound experience. Eighteen anaesthetists underwent two structured workshops (one week apart), each followed by a practice session and videorecorded assessments. Participants were randomised to a protocol-driven or non-protocol driven spinal ultrasound teaching program. Two experts rated each individual's performance using a global rating scale (GRS), checklist and image quality scale. The primary outcome was the mean difference in GRS score between the two workshops, analysed using linear mixed models. Intraclass correlation coefficients were calculated to assess agreement between assessors' ratings. A total of 108 ultrasound scans were performed on five pregnant volunteers during the assessment periods. After adjusting for confounders, GRS scores increased on all three rating scales at the second workshop, this increase being 6.01 points (95% confidence interval 4.56 to 7.46, P<0.001) from a mean score of 28.4 (95% confidence interval 24.8 to 32.0). There was no significant difference in the scores between the two teaching groups (difference in GRS scores=1.36 points, 95% confidence interval -0.77 to 3.50, P=0.211). Intraclass correlation coefficients showed substantial assessor agreement for all three assessment methods (range 0.59 to 0.89). The results demonstrate that programmed spinal ultrasound training sessions involving practice with guidance and feedback from an expert, whether protocol-based or non-protocol based, lead to improved performance.

Introduction: The SAFE handover tool was developed to reduce critical omissions during handovers in obstetric anaesthesia. It comprises a simple proforma onto which the outgoing team documents patients who fall into one of four anaesthetically relevant categories: Sick patients; At-risk patients (of emergency caesarean section, major haemorrhage or anaesthetic problems); Follow-ups; and Epidurals. We hypothesised that its use would reduce the number of critical omissions at handover., Methods: The efficacy of the SAFE handover tool was assessed through several audit cycles in a single maternity unit. The four SAFE categories were considered the gold standard, since they encompassed the consensus opinion of senior obstetric anaesthetists with respect to parturients they most wanted to know about at handover. Against these criteria it was possible to compare the number of cases that should have been handed-over against the number that were actually handed-over., Results: After implementation of the handover tool, patients were four times more likely to be handed-over than without the use of the tool: an increase from 49% to 79% of relevant cases (P<0.0001, OR 4.1, 95% CI 2.19-7.6). The handover tool was particularly effective at increasing the handover rates of Sick and At-risk parturients, which increased from 21% to 67% (P<0.0001, OR 7.7, 95% CI 2.7-21.7) and 25% to 78% (P<0.01, OR 9.9, 95% CI 1.6-61.6), respectively., Conclusion: The SAFE handover tool significantly increased handover rates of anaesthetically relevant parturients. It is easy to remember and consistent with UK National Health Service Litigation Authority's guidance on risk management in maternity units., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Introduction: Factor XI deficiency is predominantly found in the Ashkenazi Jewish population with a prevalence of 9%, but also seen in other ethnicities. Little information is available on obstetric anesthesia management in women with Factor XI deficiency. Therefore, we undertook a study to evaluate obstetric, anesthetic and perinatal outcomes in parturients with Factor XI deficiency., Methods: A retrospective study was conducted with chart reviews from 1996 to 2011 resulted in 74 women with Factor XI level deficiency. We compared anesthetic and obstetric management in parturients with low (≤30%) level of Factor XI to those with higher levels., Results: Ninety-one pregnancy outcomes were reviewed in these 74 women with Factor XI deficiency. Forty-three women had levels ≤30% in 46 labors while 31 women had levels >30% in 45 labors. Women with low levels of Factor XI were significantly more likely to receive FFP and less likely to receive neuroaxial anesthesia. There were no anesthetic complications and no difference in mode of delivery or neonatal outcomes., Discussion: This study is the first step in building a national database for anesthetic cases and outcomes of parturients with Factor XI deficiency. Further efforts must be made to provide safe analgesia for these women.

Background: In the UK earlier discharge of patients following elective caesarean section would require that more patients are discharged the day after surgery. The introduction of enhanced recovery in other specialties has resulted in shorter postoperative stay. We surveyed current U.K. practice to find whether this was consistent with enhanced recovery and what changes units would need to introduce to establish such a programme., Methods: We conducted an Obstetric Anaesthetists' Association approved electronic survey of all the U.K. lead obstetric anaesthetists between March and May 2013., Results: A response rate of 81% was achieved with 96% of those who responded supporting the concept of enhanced recovery. Only 4% of units routinely discharged their patients on day one. There were a number of practices consistent with enhanced recovery. Postoperative pain was controlled by regular paracetamol (97%) and non-steroidal anti-inflammatory drugs (100% when not contraindicated), with oral opioids (68%) being used for breakthrough pain. Over 70% of units allowed minimal interruption of perioperative oral intake and 72% of units mobilised their patients within 12h of surgery or when the neuraxial block had worn off. In contrast, a minority of units monitored patient temperature in theatre (27%) or used active warming (18%), and 28% routinely removed the urinary catheter within 12h of surgery or when the neuraxial block had worn off. Regarding neonatal recovery, only 23% reported using delayed cord clamping and 53% used skin-to-skin contact in theatre., Conclusion: Most obstetric units support the concept of enhanced recovery following caesarean section and many could introduce a programme for elective surgery with relatively small changes in patient care., (Copyright © 2013 Elsevier Ltd. All rights reserved.)